Tuesday, November 21, 2017

As the Italians say, it’s been
raining on wet ground. Following my recent blog entry on contraception in Italy
I received several emails from readers asking whether the rock-bottom Italian
birth rate might be the result of a sky-high abortion rate. By amazing
coincidence, two days later the New York Times published an article
about abortions in Italy and how hard it can be to get one. So the subject matter
of this post is overdetermined – I get to write a wonky post about abortions in
Italy at the same time as firing off a Letter to the Editor.

Amazingly, the Italian Parliament
legalized first-trimester abortion in public hospitals back in 1978, making it available
on demand and free of charge on the National Health Service. Three years later
a nominally Catholic electorate roundly scotched a Church-promoted national
referendum that tried to re-criminalize it. The Church retreated licking its
wounds but eventually hit on an excellent means of sabotage: conscientious
objection. The law’s option for gynecologists to refuse to participate was
originally intended to remain buried in the fine print but by now 70% of all Italian
gynecologists are registered as conscientious objectors. So waiting lists,
despite shrinking due to the increasing use of pills rather than surgery, are
still scandalously
long. One out of three women seeking a legal abortion is
given an appointment more than two weeks away, which drives many (20%, it’s
estimated) to get one illegally instead.

As the Times article points out,
it’s obvious that conscientious objection and Catholicism are related. But the
Church uses stronger weapons than mere moral persuasion in its promotion. I
explain in the letter I submitted (in vain) to The Times:

To The Editor,

In her otherwise excellent article, “Abortion in Italy, a Right Wronged,” Ilaria Maria Sala omits one crucial element
in why so many Italian gynecologists register as conscientious objectors. In
addition to the genuine religious convictions of some, and the fear of others
that performing abortions would tarnish their reputation, there are more
practical threats to their livelihoods. Abortions are performed only in public
hospitals, by gynecologists employed by the National Health Service. Many
public system gynecologists, however, want also to be able to treat their own
patients, after hours, within a large network of private hospitals which in
Italy are mostly owned and/or run by the Catholic Church. Any physician who
performs abortions – supposedly, any physician who even just counsels patients
about them – is barred from operating, delivering babies, or hospitalizing
patients in any Church-run institution. Thus a gynecologist who wants to be
able to work privately in Italy is virtually obliged to declare him- or herself
a conscientious objector to abortion.

So to get back to our original
question, do abortions have a big influence on Italian birth rates? Nope. Italy
has one of the lowest
abortion rates in western Europe. In proportion to the number of babies born
alive Swedish women have 40% more abortions than Italians, French women 35%,
English and Spanish about 18%. And only one in five abortions performed on
Italian women is a repeat procedure.

Since legalization there have been
fewer
and fewer abortions in Italy, especially among citizens – non-Italians,
many of them immigrants from developing countries, now account for one in
three.

The bottom line is that the Church
has indeed succeeded in mounting barriers to abortion, especially in southern Italy, but those barriers can be overcome. And women here don’t have to run the gauntlet of
demonstrators you find screaming abuse outside the entrances to abortion
clinics in the USA. And no one has ever shot an Italian abortionist.

Friday, November 10, 2017

When it comes to birth control
Italians have a preference for the “natural” you can trace to the Catholic
Church, which long since banished the contraceptive diaphragm and persuaded
most people not to use IUDs, Pills, patches, rings, implants, Depo-Provera
shots, or sterilization. Condoms, which Italians usually call preservativi – watch out what word you
use for jam or you’ll get snickers – are fairly popular. But what most people do
to avoid pregnancy is what they call stare
attenti or being careful: watching the calendar, and using withdrawal on
days they think (rightly or wrongly) that they’re fertile.

Nonetheless, the Italian birth rate
hovers between the lowest and the next-to-lowest on the planet. How come? The
main explanation is that – contrary to what I was taught in medical school –
withdrawal works. It helps that Italy has a surprising culture of shared
responsibility between men and women in this particular realm, so guys are more
willing to use condoms, and more skilled at pulling out.

Friday, November 3, 2017

Fraud is a worldwide sport but in Italy, land of
Verdi and Puccini, it may get embellished by melodrama. Some years back the
administrators at Rome’s Jewish Hospital figured out a solution for their
hospital’s unbalanced budget and their own empty pockets: soak the National
Health Service. In 2014, after some 20 million dollars had been siphoned off, their
scheme hit the headlines with a bang. At first the conspirators had just been overcharging
dental fillings as implants, or outpatient procedures as though the patient had
spent the night. Poca roba, small
stuff, as the Italians say.

The Jewish Hospital staff gradually escalated to shameless
double billing and to inventing “ghost operations,” until one day the
authorities planned a surprise inspection. That was when the plotters found
themselves having to call on their native theatrical flair. A mole inside the
regional National Health Service office tipped them off about the upcoming raid,
giving them time to dress up an orthopedic ward as though it belonged to
dentistry (don’t ask) and a private ward as though it were public. Phony
medical charts were fabricated, complete with temperature readings and lab
tests, and flocks of patients were shuttled between one ward and another. One
hospital chief was caught on a wire tap telling a crony: “The inspectors are
coming, it’s time for us to put our little piece of Hollywood into motion. You
empty out the patients on the fifth floor, and we’ll cross our fingers.”

Now don’t be shocked, but even in the USA public
medicine loses billions every year to greedy cheats. There are macroscams where
clinics bill for medications that were never given or buy used equipment as
though it were new. Middling scams where doctors and opiate pushers collude. And
microscams – the only Medicare bill I’ve happened to see with my own eyes,
related to a 3-minute visit for a non-smoker’s athlete’s foot, tossed in a
charge for “Tobacco counseling.” All effective in their way, but sadly lacking
in pizzazz.

So who’s worse? According to reports commissioned by the
European Union, 13% of all the money spent on health in Italy gets lost through
corruption, whereas outright medical fraud in the US is said to add up to only 3%. But if you join me
in considering obscene overpricing to be tantamount to fraud – mebendazole pills for deworming your
kids, two for a buck at your local Italian pharmacy, cost $442 per pill wholesale in the USA, and many American
Emergency Rooms charge patients $1000 just to walk in the door before even
seeing a nurse – maybe we can charitably call the contest a draw.

About Me

I moved to Rome in 1978 after finishing my training in New York, and have been practicing primary care internal medicine there ever since, treating a clientele that’s featured Roman auto mechanics and British ambassadors, Indonesian art restorers and Filipina maids, Russian poets and Ethiopian priests. When not seeing patients, doing research in psychosomatic medicine, or being the Artist's Wife to my composer husband, I've written a book about my medical adventures, Dottoressa: An American Doctor In Rome, to be published by Paul Dry Books in May 2019.